Noncardiac Surgery After PCI
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In these slides I discuss what to do with the patient post stent who needs noncardiac surgery and I discuss what to do with anti-platelet therapy in the perioperative period. Watch my YouTube description of these slides at http://youtu.be/z8Okm3_GFbU.
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Noncardiac Surgery After PCI
- 1. Noncardiac Surgery After PCI What to do? Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine
- 2. You must balance… Stent Thrombosis Bleeding
- 3. Adverse Cardiac Events Following Noncardiac Surgery in Patients With Stents Hawn, et al. JAMA 2013;310:1462
- 4. • Class I • Elective noncardiac surgery should be delayed • 14 D after balloon angioplasty • 30 D after BMS implantation • 365 D after DES implantation • Class IIb • Elective noncardiac surgery after DES implantation may be considered after 180 D if risk of further delay > risk of stent thrombosis 2014 ACC/AHA Perioperative Guidelines
- 5. • Class III (Harm) • Elective noncardiac surgery in which DAPT will need to be discontinued should not be performed within • 30 D after BMS • 365 D after DES • If elective noncardiac surgery is needed within 1- 12 months then place BMS with 4-6 wks of DAPT with continuation of ASA perioperatively 2014 ACC/AHA Perioperative Guidelines
- 6. Approach to patients who need surgery after PCI Wait 4-6 weeks Wait 12 months Continue dual antiplatelet therapy if surgery needed before completion of recommended therapy No matter what continue at least aspirin* * Except for neurosurgery, post eye, middle ear, and prostate
- 8. • Aspirin (and aspirin/dipyridamole) • POISE-2 trial (N Engl J Med 2014; 370:1494-1503) suggests that aspirin is of no benefit in patients at moderate to high risk for cardiovascular events who are undergoing noncardiac surgery • Stop 7-10 days prior to surgery • Bleeding time is a poor predictor of perioperative hemorrhage Managing antiplatelet agents in the perioperative period
- 9. • Platelet P2Y12 receptor blockers • Clopidogrel and ticagrelor: stop at least 5 days before surgery • Prasugrel: stop at least 7 days before surgery • Cilostazol • Selective phosphodiesterase-3 enzyme inhibitor with weak, reversible antiplatelet activity • Stop 5 days before surgery Managing antiplatelet agents in the perioperative period
Editor's Notes
- Noncardiac surgery after recent stent implantation is fairly common. These patients are at increased risk of adverse cardiac events and bleeding. These slides will review the management of these patients. This is a field undergoing intensive study and recommendations could change at any minute. It is best to consult with the cardiologist caring for the patient needing surgery.
- The issue that arises in patients with recent PCI is what to do about the timing of surgery and what to do about antiplatelet therapy. The issue revolves around weighing the risk of stent thrombosis with stopping antiplatelet therapy to the risk of bleeding with continuing it. In most cases, the risk of stent thrombosis outweighs bleeding risk.
- Hawn and colleagues performed a large retrospective cohort study on 28,000 veterans who underwent noncardiac surgery within 24 months of PCI. Overall, the rate of MACE (all-cause mortality, MI, and cardiac revascularization) was 4.7% at 30 days (top panel). Figure A shows the rates of MACE by stent type (drug eluting stent vs bare metal stent). The rates are high early but level off after 6 months. Furthermore, bare metal stents have a slightly higher rate that might be due to higher risk patients who will need surgery shortly after PCI being preferentially given bare metal stents. Finally, Table 3 shows the top 3 (of 12) predictors of MACE: nonelective surgical admission, having an MI within the 6 mos prior to surgery, and high RCRI score. Stent type was the least important of the predictors in their model.
- These are the updated recommendations by the ACC on the timing of surgery post PCI.
- These are the updated recommendations by the ACC on the timing of surgery post PCI.
- So what should you do if you have a bare metal stent (BMS) or a drug eluting stent (DES): BMS- wait at least 6 weeks after stent placement before performing elective noncardiac surgery. DES- wait at least 6 months (though current guidelines recommend 12 months) after stent placement before performing elective noncardiac surgery. Dual antiplatelet therapy (DAT) should be continued thru the perioperative period is surgery must be conducted prior to the recommended DAT treatment duration. If the risk of stent thrombosis is lower than the risk of bleeding on DAT and it is decided to stop clopidogrel (or similar drug) aspirin should be continued throughout the perioperative period. Clopidogrel (or similar drug) should be restarted asap after surgery. The risk of stent thrombosis is highest in the first days after surgery. Certain surgical procedures (like spinal or intracranial surgery, posterior eye surgery and prostate surgery) carry such catastrophic outcomes related to bleeding that all antiplatelet therapy must be stopped perioperatively. Definitely consult with a cardiologist in these patients as they might need urgent PCI for stent thrombosis.
- This is a graphic display of the 2014 guidelines on the timing of surgery peristent implantation and antiplatelet therapy decision making in the peristent placement period.
- Aspirin doesn’t seem to be beneficial in patients at risk for perioperative events (POISE 2 trial). Approximately 23% of the study population had known CAD but I couldn’t find any report of outcomes in this group to know if continuing aspirin was beneficial or not. The ACC guideline states the continuation of aspirin in these patients might be reasonable.